Healthcare Provider Details

I. General information

NPI: 1629605167
Provider Name (Legal Business Name): TEJAL DESAI DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 SEAVIEW AVE FL 1
STATEN ISLAND NY
10305-3401
US

IV. Provider business mailing address

1 LYSBETH LN
MATAWAN NJ
07747-7004
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-2752
  • Fax:
Mailing address:
  • Phone: 718-226-2752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number325987
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: